Dental Program for Active Participants in All Plans and All Retirees January 2018

Transcription

1 Dental Program for Active Participants in All Plans and All Retirees January 2018 i

2 Table of Contents Introduction... 1 Your Dental Program Choices... 1 Dental/Orthodontic Opt-Out Choice (Applicable only to Active Participants)... 1 Choosing A Plan... 2 Changing Plans... 2 Cost of Coverage... 2 Indemnity Dental Plan... 2 Preauthorization of Benefits... 2 Hospitalization for Dental Conditions... 3 The Plan s Benefits... 3 Deductible... 3 Coinsurance... 3 Annual Maximum... 4 Covered Procedures... 4 Preventive and Diagnostic Services... 4 Basic and Major Restorative Services... 5 Endodontic Services... 6 Periodontal Services... 6 Prosthodontics... 7 Oral Surgery... 8 Other Services... 8 Additional Accident Benefit... 8 Explanation of Benefits Codes and Messages... 9 Prepaid Dental Plans Prepaid Dental Plan Oices Exclusions and Limitations Claiming Benefits Assignment of Benefits Coordination of Benefits Important Information About the Plan About This Section Plan Name and Number Type of Plan Plan Sponsor Name of Plan Sponsor Address of Fund Oice Mailing Address Telephone Employer Identification Number Plan Year Plan Administrator Agent for Service of Legal Process Contributing Employers Plan Records Documents Claims and Appeals Procedures for Dental Claims Filing Claims Processing Claims Filing an Appeal of a Claim Determination Processing Your Appeal General Rules Future of The Plan Plan Finances Collective Bargaining Agreements Board of Trustees Names And Addresses Of Members Of The Joint Board Of Trustees Union Trustees Employer Trustees Prepaid Dental Plans ERISA Statement of Rights Receive Information About Your Plan and Benefits Continue Group Health Plan Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Assistance with Your Questions Glossary of Common Dental Terms Participating Union Locals UFCW UFCW Local UFCW Local UFCW Local UFCW Local UFCW Local UFCW Local Administrative Oice of The Fund Address of Fund Oice Mailing Address Website ii

3 Dental Program Introduction Dental care is an important part of maintaining good health. The Fund s Dental Program will help you meet the cost of dental services for you and your family, if eligible. The Dental Program oers you a choice of two plans: The Indemnity Dental Plan is a traditional dental plan that allows you to use any dentist you choose. A Prepaid Dental Plan, similar to an HMO. You must use the services of a dentist who is part of the Prepaid Dental Center you choose. Both plans provide benefits for diagnostic services, preventive and restorative services. The dierences between the Indemnity Dental Plan and a Prepaid Dental Plan are in your choice of dentists and in the amount you pay for the dental treatment you receive. Both dental plans are subject to exclusions and limitations. This book will help you understand what is and what is not covered. Please note that benefits for orthodontia are described in a separate booklet. This book is only a summary of the benefits provided by the United Food & Commercial Workers Unions and Food Employers Benefit Fund. It is subject to the provisions of the oicial Plan documents and cannot modify or aect the Plan documents in any way. In case of any dierences between this booklet and the oicial Plan documents, the Plan documents will prevail. Neither you nor any of your eligible Dependents shall earn any rights because of any statement in, or omission from, this book. The provisions of the Plan documents cannot be modified or amended in any way by any statement or promise made by any person, including employees of the Fund Oice, the Unions or any Employer. If you are an Active participant and enrolled in medical coverage, dental coverage is provided as well. For specific details on eligibility, please check your enrollment form instructions or check online at scufcwfunds.com. Retirees participating in the Dental Program pay a premium that also covers their eligible dependents. Your Dental Program Choices You have a choice between the Indemnity Dental Plan and one of the Prepaid Dental Plans oered by the Fund. If you enroll in the Indemnity Dental Plan, you may receive dental care from any dentist of your choice. This Plan provides benefits according to Plan allowances, as listed on the Dental Schedule of Allowances provided by the Fund Oice. You pay whatever is not paid or covered by the Plan. If you choose a Prepaid Dental Plan, you must live in the area served by that Plan (i.e., Service Area), and you can receive dental care only from a dentist who is part of that Plan. The Prepaid Dental Plans cover many routine services at no cost to you, and you pay only a copayment for major dental services. A list of the Prepaid Dental Plan Oices is on page 16. You must remain in the Plan you choose until the next annual Open Enrollment (please refer to Changing Plans below). Whether you choose the Indemnity Dental Plan or a Prepaid Dental Plan, your eligible Dependents must be enrolled in the same Plan. If you have an eligible dependent child age 19 through 25 who is eligible for coverage but who lives outside the Prepaid Dental Plan Service Area, he or she is automatically covered by the Indemnity Dental Plan. Dental/Orthodontic Opt-Out Choice (Applicable only to Active Participants) The Fund s Dental/Orthodontic benefits are automatically included with your medical coverage. However, you may opt out of (i.e., drop) Dental/Orthodontic coverage during Open Enrollment. There is no advantage to you for dropping Dental/ Orthodontic coverage. If you do, your payroll deductions will not go down. You will pay the same amount for health care benefits with or without Dental/Orthodontic coverage. What s more, your covered family members (if any) will also lose the coverage you drop. If you want to opt out of Dental/Orthodontic coverage, call the Fund Oice for more information. 1

4 Choosing A Plan You choose a dental plan by filling out the Fund s Enrollment Form, available from your Union Local or the Fund Oice. On the form, you must indicate which dental plan you choose and the names of the eligible dependents you wish to enroll. Your dependents will be enrolled in the same plan that you select for yourself. If you acquire a new eligible dependent (for example, if you get married) after your initial enrollment and you wish to enroll him or her in the Plan, you must promptly complete an additional Enrollment Form. Changing Plans You may elect to change dental plans once each year during the Open Enrollment period. The choice you make during Open Enrollment generally becomes eective on January 1st and stays in eect for 12 months. If you are a Retiree, once you disenroll from the Dental Plan, you must wait until the third Open Enrollment after rejecting dental coverage to enroll again. If you move out of the Service Area of a Prepaid Dental Plan in which you are enrolled, you may change to the Indemnity Dental Plan or to another Prepaid Dental Plan. Cost of Coverage Active employees are required to pay a weekly contribution to premiums that includes both medical and dental coverage. If you are a Retiree who elects dental coverage, you pay for this coverage and must enroll for a full year s coverage. Indemnity Dental Plan If you choose coverage under the Indemnity Dental Plan, you may use any dentist of your choice. If you have dental care outside the United States, however, the charges will not be eligible for benefit payment under the Plan, unless: Treatment is for Emergency care, or You are an eligible Retiree living permanently abroad, or For services performed in Mexico, proper documentation of treatment, including x-rays, is supplied to the Fund with each claim for benefits. The Indemnity Dental Plan provides benefits for Covered Procedures, which are specific services that are covered by the Plan. Covered Procedures include: Preventive & Diagnostic services Basic Restorative services Major Restorative services These procedures are described in more detail beginning on page 4. Preauthorization of Benefits Preauthorization of benefits allows the Fund to review a proposed treatment plan in advance and resolve any questions before, rather than after, work has been done. As a result, both you and your dentist will know in advance which procedures are covered. A treatment plan is the dentist s report that: Itemizes recommended services, Shows the charge for each service, and Is accompanied by supporting diagnostic quality x-rays and other diagnostic information when required or requested by the Plan s dental consultant. All dental claims are subject to review by the Fund. If the total charges are expected to be more than $500, we recommend that your dentist s proposed treatment plan be submitted to and reviewed by the Fund so that dental benefits can be preauthorized. The Fund will authorize dental benefits only for treatment or services that are covered by the Plan and are dentally necessary. Diagnostic quality x-rays should be provided to the Fund with the preauthorization request. Study models or oral/facial photographs should be provided upon request. The following requests for preauthorization must be submitted with the indicated materials: Fixed bridges, implants and partial dentures right and left posterior bitewing x-rays and/or full mouth periapical x-rays. Crowns and other cast restorations x-rays and/or study models. Periodontal procedures current x-rays and periodontal pocket charting. X X Periodontal surgery following initial therapy pre- and post-root planing periodontal pocket measurements and x-rays. 2

5 Dental Program To obtain preauthorization, your dentist should submit the proposed treatment plan with the appropriate supporting documentation to the Fund Oice. The Fund Oice will send a response form to you and your dentist indicating services that were authorized. In the event treatment is rendered without preauthorization, the Fund will try to retrospectively review your claim, diagnostic quality x-rays and other supporting documentation to determine if your treatment will be covered by the Plan and was dentally necessary. Preauthorization is the only way you can know what will be covered before the work is done. For authorized treatment, reimbursement is subject to scheduled Plan Allowances, deductibles and maximums in eect at the time services are rendered. If you lose eligibility for dental coverage, dental benefits can be extended for certain treatments if you received approved preauthorization for them before you became ineligible. Benefits will be extended if: Request for preauthorization was received prior to termination of eligibility, The services were preauthorized in accordance with Fund standards, and Treatment begins no later than 35 days following the date of mailing of the approved authorization. This extension shall not apply in any case where benefits are available through any other group or prepaid dental coverage. Hospitalization for Dental Conditions If you require hospitalization for treatment of a covered dental condition, the inpatient stay or outpatient visit must be authorized by the Fund Oice before any charges are incurred. Authorization will be granted if medical necessity for hospitalization is certified in writing by a physician. If approved, covered services will be paid: Under the Indemnity Dental Plan for covered dental services, and Under the Indemnity PPO Medical Plan for covered hospital expenses. The Plan s Benefits The Indemnity Dental Plan will pay a percentage of the Covered Charges for services performed by your dentist or hygienist. You must satisfy the deductible each year. Benefits payments are limited to the maximum for each calendar year. You pay the dierence between the dentist s charges and the amount paid by the Plan. Procedures that are not listed in the Plan schedule of allowances will not be covered and no benefits will be paid for those procedures. You will be responsible for those charges. Deductible A deductible is a specific amount of expense that you will pay before the Plan begins to pay its benefits. You may satisfy the deductible with a combination of dental expenses. Charges that are not covered by the Plan or that exceed the schedule of allowances are not applied to the deductible, even though you must pay them yourself. The deductible is waived for preventive and diagnostic services. For all other services, the deductible is $50 for each person during each calendar year, but no more than $150 will be required for all of your family members. The dental deductible is not eligible for HRA reimbursement. Coinsurance Coinsurance is your percentage share of the charges for the dental services you receive. It is not a set amount and will vary by the cost of the procedures, although the percentage remains the same. The coinsurance is waived for preventive and diagnostic services and the Plan will pay 100% of the charges, but not to exceed the amounts in the schedule of allowances. For all other services, the Covered Charges will be limited to the amounts shown in the schedule of allowances. The Plan will pay the percentage of covered charges as follows: Preventive & Diagnostic 100% Basic Restorative Services 80% Major Restorative Services 70% Preventive and diagnostic services include oral examination, prophylaxis and x-rays. See page 4 for more information. Basic restorative services include fillings, crowns, extractions, endodontics and minor periodontal treatment. Major restorative services include prosthodontics, such as bridges and dentures and major periodontal treatment. Dental coinsurance is not eligible for HRA reimbursement. 3

6 Annual Maximum Dental benefits are limited to the maximum for each calendar year for each person, as shown: Gold, Platinum, Platinum Plus Silver Retiree Plan A $1,800 Plan B $1,400 Plan A $1,000 Plan B $1,150 $1,800 In accordance with the requirements in the Patient Protection and Aordable Care Act eective April 1, 2011, the annual dollar limit for dental services will no longer apply to pediatric dental care (up to age 18). Please note that all orthodontic services will still be subject to the lifetime dollar limits. Covered Procedures You and your covered eligible Dependents are eligible for payment for the following covered dental procedures. Preventive and Diagnostic Services Oral Evaluations Dental evaluation once every six months. This benefit includes the completion of treatment plans. Evaluation or consultation by a specialist when performed by a periodontist, endodontist, pedodontist, prosthodontist or oral surgeon. Coverage is limited to one evaluation by each type of specialist per dental treatment. Tests and Laboratory Evaluations Study models and oral/facial photographs only if they are requested by the Fund or are used by the Fund in the evaluation of a case. Oral pathology laboratory charges for the evaluation of oral tissue. X-rays f f Full mouth x-rays or panoramic x-rays once every five years unless required for a specific diagnosis. Panoramic film taken in conjunction with bitewing and/or anterior periapical films will be considered the same as a regular full mouth x-ray series. Checkup x-rays once every 12 months (consisting of up to two periapical and two to four bitewing films). X-rays are covered only if they are of diagnostic quality. X-rays are covered when required for diagnostic purposes or if requested by the Fund. Prophylaxis Once every six months for adults and children. Benefits may be provided on a more frequent basis if preauthorized by the Fund dental consultant. To obtain preauthorization for payment of additional prophylaxis benefits, your dentist must submit: a treatment plan stating the frequency requested, current x-rays, and current periodontal charting. Benefits are not payable for both a prophylaxis and a root planing when performed on the same day. Fluoride Treatment Once every six months for patients under age 19. Benefits may be provided on a more frequent basis if required and authorized by the Fund. Benefits may be provided for patients age 19 and older if medically appropriate and authorized by the Fund. Sealants Once every 24 months for patients under age 19. Retreatment only to a single tooth per quadrant. Placement of sealants is not covered in conjunction with a filling on the same tooth surface or where the tooth was previously filled. Space Maintainers Unilateral or bilateral posterior space maintainers are covered when the space to be maintained is open and the crowns of erupting teeth have not penetrated the alveolar bone. Anterior space maintainers are not covered. Two unilateral space maintainers in the same arch will be covered the same as a bilateral space maintainer. Replacement of space maintainers is covered after prior space maintainers have been in place for at least 24 months. 4

7 Dental Program Basic and Major Restorative Services Fillings Separate proximal restorations in anterior teeth are covered the same as single surface restorations. Occlusal restorations in conjunction with buccal or lingual restorations in the same tooth are covered the same as single surface fillings. Restorations in teeth where sealants have been applied are covered after 12 months or more have elapsed since the application of sealants. Benefits for replacement of a filling are payable only once in 24 months. Multiple fillings on a single tooth surface are covered as a single surface filling. Inlays, Onlays, Crowns, Labial Veneers Cast restoration benefits are payable for patients 16 years of age or older. An allowance may be made for a pre-fabricated resin or stainless-steel crown for patients under 16. Benefits are provided for two-surface and threesurface inlays and onlays. Dental necessity must be documented by x-rays and/or study models showing extensive coronal destruction. Benefits are payable if the tooth cannot be restored with an amalgam or composite filling. Benefits for replacement of a cast restoration are limited to once every five years. If, within 12 months, a filling requires replacement with a cast restoration, benefits paid for the filling will be deducted from the benefit payable for the cast restoration. Benefits will be paid for repair or recementation of an inlay, onlay, crown or veneer after 12 months or more have elapsed since the initial placement or previous recementation or repair. Benefits are payable for replacement of a prefabricated resin or stainless-steel crown 24 months after initial placement. f f Benefits are payable for restoration of tooth structure loss due to abrasion, attrition or erosion when there is complete or near complete loss of enamel and it has been determined to be dentally necessary. Implant Placement and Restoration Services The surgical placement of an implant is covered only to replace a single missing tooth where the Plan would authorize benefits for a three unit fixed bridge and neither tooth adjacent to the implant requires a cast restoration. Implant placement is not covered if there are two or more adjacent missing teeth. Benefits are payable for an implant or abutment supported crown if the restoration is placed on a covered implant. (Please refer to Procedure Codes under Basic Restorative, limitations on benefits for cast restorations [including crowns] and for prosthodontics listed on the Dental Schedule of Allowances.) If a restoration on an implant or implants replaces two or more missing teeth that are next to each other, the benefit payable is the allowance for a removable denture. Benefits are not payable for a restoration on an implant or implants if there is evidence of implant failure. Benefits are not payable for removal of a failing implant. Buildup Charges for buildups, including pins, are covered when x-rays document insuicient tooth structure to support a crown. Benefits for replacement are payable every 24 months. Posts Posts are covered when insuicient coronal structure remains to retain the crown restoration, and dental necessity is documented by x-rays taken prior to root canal therapy. Benefits for cast posts are payable every five years, pre-fabricated posts every two years. 5

8 Endodontic Services Plan allowances for endodontic therapy include initial treatment, temporary fillings, follow-up care and interim and final x-rays. Pulpal Therapy, Primary Teeth Initial pulpal therapy or pulpotomy only when performed on primary teeth that have not begun to exfoliate. Root Canal Therapy Root canal therapy, including initial treatment, interim and final x-rays, temporary fillings and follow-up care. Benefits are payable upon receipt by the Fund Oice of x-ray documentation indicating satisfactory root canal treatment. Retreatment Retreatment of root canal therapy (including apicoectomy and/or retrofill) only if dental necessity is documented, and treatment is performed at least one year after initial therapy. Periodontal Services Periodontal Scaling and Root Planing The benefit payable for root planing is determined by the number of teeth in each quadrant that require treatment. The full quadrant allowance is payable for four or more teeth. The half quadrant allowance is payable for one to three teeth. A tooth will be considered to require treatment if the pocket depth is greater than four millimeters and there is evidence of bone loss or calculus present. f f The Plan covers root planing in each quadrant once in a 24-month period. Periodontal Reevaluation (Limited Oral Evaluation) Periodontal reevaluation is covered once in 24 months when performed at least four weeks after a course of nonsurgical periodontal procedures (scaling and root planing). Periodontal Surgery Benefits are payable for periodontal surgery only if dental necessity is documented. The surgery must follow initial therapy of scaling, root planing and reevaluation. Benefits for periodontal surgery are payable once in a 24-month period. Soft Tissue Graft Benefits are payable for soft tissue graft procedures on a per-site basis (including donor site surgery) when submitted documentation demonstrates complete lack of attached gingiva or progressive attached gingival recession of four millimeters or greater. Periodontal Maintenance Benefits are payable for a first periodontal maintenance procedure when performed at least three months after the completion of periodontal surgery. Subject to approval, benefits are thereafter payable every three months. Bone Grafts Benefits are payable for a bone graft for a present natural tooth, but not in conjunction with an implant. Benefit payment is limited to once in a three-year period. Clinical Crown Lengthening Crown lengthening is covered when dental necessity has been established by submission of pretreatment x-rays that demonstrate coronal destruction at or below the level of the alveolar bone. 6

9 Dental Program Prosthodontics Full or Partial Dentures Replacement of missing teeth with full or partial removable dentures, using standard techniques. The allowance includes adjustments following placement. Teeth to be replaced need not be extracted while the Plan covers you to qualify for replacement. Replacement of an existing removable prosthesis is limited to once every five years. Replacement of a second molar will be covered only as part of a prosthesis that replaces adjacent missing teeth. A removable partial denture and a fixed posterior bridge in the same arch will be covered if they are placed at least five years apart. The Plan does not cover the following: Cast frame removable partial dentures for children under age 16. Specialized techniques, personalization or characterization. Precision attachments. Experimental procedures. Surgical correction by grafts for the purpose of denture retention. Interocclusal recording and/or analysis. Unusual diagnostic techniques. Procedures associated with overdentures. Stressbreakers. Appliances to alter vertical dimension. Interim Partial Dentures Interim partial dentures for recently extracted anterior teeth will be covered when replacement with a permanent prosthesis occurs no sooner than two months following placement of the interim partial denture. Tissue Conditioning Treatments Up to two tissue conditioning treatments per denture are covered before or after the denture is made, relined or rebased. Denture Rebase and Reline Benefits are payable for an oice reline six months following placement of a denture or three months following placement of an immediate denture. Benefits are payable for a laboratory reline six months after placement of any denture. Benefits are payable for a reline 12 months after a rebase or a previous reline. A rebase is covered two years after denture placement or reline and once every two years thereafter. Fixed Bridge Fixed bridge benefits are payable for patients 16 years of age or older. Benefits for replacement of a fixed bridge are limited to once every five years. Benefits are not payable for both a posterior fixed bridge and a removable partial denture in the same arch within a five-year period. Distal extension posterior cantilevered pontics are not covered. Replacement of a missing tooth is not covered where the space is largely closed and neither of the abutment teeth otherwise requires crown restoration. Replacement of second molars is not covered unless as part of a prosthesis replacing adjacent missing teeth. Benefits are not payable for a fixed prosthesis if a large number of teeth are missing in the same arch and/or moderate to advanced periodontal bone loss is demonstrated by x-rays. Benefits will be paid for repair or recementation of a fixed bridge if 12 months or more have elapsed since the initial placement or previous recementation or repair. Benefits are payable for a bridge replacing a congenitally missing tooth provided the space would otherwise qualify for bridge placement. f f Dentally necessary splinted crowns are covered when part of a fixed bridge. 7

10 Oral Surgery Extractions Benefits for extractions include local anesthesia, postoperative care and x-rays after surgery. Removal of Tumors, Cysts And Neoplasms Biopsies and/or removal of cysts and neoplasms are covered when a copy of an oral pathology report is submitted with the claim. Anesthesia General anesthesia is covered when administered by an oral surgeon or anesthesiologist for partial bony and full bony extractions. General anesthesia may be covered for children under age 8 who have neurological or other medical conditions, for disabled patients, for patients who have sustained significant facial/dental trauma, for removal of tumors/cysts/neoplasms or for other complex procedures following authorization by the Fund. Premedication Premedication is covered for patients under age 5 and for documented handicapped or uncontrollable patients. Other Services Temporomandibular Joint Conditions Generally, benefits for treatment of TMJ conditions are available to all Participants whether enrolled in the Indemnity Dental Plan, Prepaid Dental Plan, Indemnity PPO Medical Plan or an HMO. Some nonsurgical services are payable as dental benefits according to the Dental Plan allowances while surgical treatment and hospitalization are payable under the Indemnity PPO Medical Plan or by an HMO, if covered by that Plan. Benefits for an appliance to treat TMJ are payable in accordance with the Dental Plan allowances. One appliance is covered per 24-month period. Benefits are payable under the Indemnity Dental Plan, up to $500 in any 12-month period, for nonsurgical treatment of TMJ conditions, subject to the Indemnity Dental Plan s annual deductible and maximum. This includes oice visits and adjustments to appliances. f f For surgical treatment of TMJ conditions, benefits are payable under the Indemnity PPO Medical Plan for participants enrolled in the Indemnity PPO Medical Plan option. Participants enrolled in a Medical HMO must obtain treatment through their HMO. Benefits paid for nonsurgical treatment of TMJ will reduce the benefit payable for surgical treatment and will be applied toward the Indemnity Dental Plan annual maximum. Hospital benefits are payable under the Indemnity PPO Medical Plan for Participants enrolled in that plan. However, all treatment of TMJ conditions is subject to Fund requirements for preauthorization of treatment and for preauthorization of all Hospital stays. Refer to your PPO Plan Benefit Summary for the Indemnity PPO Medical Plan specific benefit information regarding coverage of TMJ. Please call the Fund if you have any questions. All treatment for TMJ must be reviewed and authorized by the Fund dental and/or medical consultant. The Plan does not cover TMJ services performed in conjunction with active orthodontic treatment. TMJ benefits are not available for patients under age 16. HMO members must obtain surgical treatment of TMJ through their HMO network. Bruxism Splint A bruxism splint or nightguard is covered for patients 16 years of age or older when dental necessity has been documented. Replacement of an existing bruxism splint or nightguard is covered 24 months after initial placement. Palliative Treatment Benefits are payable for palliative (emergency) treatment unless performed on the same day as any other procedure. Emergency exams and/or dispensing prescriptions are not recognized as palliative treatment under the Plan. Please see Exclusions and Limitations beginning on page 16. Additional Accident Benefit In case of an accidental injury to a natural tooth, the Plan can provide an additional benefit of up to $750 when charges for Covered Procedures exceed Plan allowances, subject to the Indemnity Dental Plan s annual maximum. Services must be provided within 90 days after the accident occurs. The additional accident benefit covers: Examination, x-ray and repair of the injured tooth. Repair or replacement of an existing crown or bridge if there is clear evidence of injury to the supporting natural tooth. Reimplantation and/or stabilization of accidentally avulsed or displaced teeth. 8

11 Dental Program Explanation of Benefits Codes and Messages Message Code Message 001 Services performed by relatives are not covered. 002 Resubmit with: a. Patient signature. b. Participant s current signature and date. c. Signature of attending dentist. d. Correct name and/or birth date of patient. e. Date of accident, accident report and third party liability information. f. Detailed description of emergency/ palliative treatment, including tooth number(s) and/or area(s) treated. g. Copy of complete treatment records. h. Complete TMJ diagnostic records. i. Copy of oral pathology report. j. Full upper arch pretreatment diagnostic quality x-rays. k. Full lower arch pretreatment diagnostic quality x-rays. l. Pretreatment photographs. m. Pretreatment photographs or study models. n. Copy of clinical treatment records and diagnostic quality pretreatment x-rays. o. Resubmit and indicate upper or lower arch. 003 Resubmit with: a. Correct tooth number. b. Tooth number/letters using those as indicated on the claim form tooth chart to specify teeth treated. c. Tooth surface(s). d. Date service completed. e. Mounted, dated, diagnostic quality x-ray. f. Current diagnostic quality pretreatment x-ray(s). g. Diagnostic quality final root canal therapy x-ray. h. Current diagnostic quality pretreatment and final root canal therapy x-rays. i. Current diagnostic quality periapical x-ray(s). j. Current diagnostic quality full mouth, periapical and bilateral bitewing x-ray(s). k. Current diagnostic quality bitewing x-ray(s). m. Current diagnostic quality x-rays and recently dated periodontal pocket charting. n. Full mouth study models. p. Full upper arch study model. q. Full lower arch study model. r. Upper right quadrant study model. s. Upper left quadrant study model. t. Lower right quadrant study model. u. Lower left quadrant study model. v. Specific teeth numbers or quadrant involved in periodontal therapy/surgery. w. Resubmit with tooth number and reason for x-ray(s). x. Reason for x-ray. 004 Resubmit with a copy of the primary insurance explanation of benefits statement. 005 Benefits are not payable for completion of claim forms. 006 Benefits are not payable for x-rays that are not of diagnostic quality. 007 Orthodontic care is covered under a separate program and otherwise excluded. 008 Benefits are not payable for procedures performed for cosmetic reasons. 9

12 Explanation of Benefits Codes and Messages Message Code Message 009 Full mouth reconstruction and treatment of congenital malformations are not covered, except as specifically indicated. 010 Hospitalization for dental diagnosis or treatment is covered only when medically necessary and preauthorized. 011 Allowance for procedure(s) performed includes post-treatment x-rays. 012 A bitewing x-ray series (including periapicals) is covered once in 12 months. 013 Oral evaluations are covered once in 6 months. 014 Full mouth x-rays or panoramic x-rays are covered once in five years, unless required for specific diagnostic reasons. 015 A panoramic x-ray when accompanied by two or more bitewing and/or periapical anterior films is considered the same as a full mouth x-ray series. 016 Study models are not covered unless they are requested by the Fund or are used by the Fund in the evaluation of a case. 017 Prophylaxis is covered once in six months unless need for greater frequency is documented. 018 Fluoride treatment is covered once every six months for persons under age 19, unless specific need for more frequent treatment can be demonstrated. 019 Benefits are not payable for prophylaxis, root planing and/or periodontal surgery performed on the same day. 020 Sealants are covered for patients under age 19. Retreatment is covered after 24 months for one tooth per quadrant. 021 Oral hygiene instruction is not covered 022 Flouride treatment is only covered for persons age 19 and older if medically appropriate as determined by dental consultant review. 023 A benefit is payable for a bilateral space maintainer when bilateral space maintenance is required in the same arch. 024 Space maintainers are not covered when spaces have closed or permanent teeth have penetrated the alveolar bone. 025 Replacement of fillings in less than two years is not covered. 026 Separate proximal restorations in anterior teeth are covered as a single surface restoration. 027 Benefits are payable for only one filling per tooth surface per treatment. 028 Occlusal restorations in conjunction with buccal or lingual restorations in the same tooth are covered as single surface restorations. 029 A benefit for a buildup, including pins, is payable only when there is insuicient tooth structure to support a crown. 030 The allowance for endodontic therapy includes initial treatment, temporary fillings, follow-up care, and interim and final x-rays. 031 Pulp caps and bases are not covered. 032 The alternate benefit payable is the allowance for procedure code Retreatment of root canal therapy (including apicoectomy and/or retrofill) is covered only when need is documented and no sooner than 12 months after initial treatment. 034 Occlusal adjustments are not covered. 035 Pretreatment x-rays are required when claim is submitted for payment. 036 Copy of oral pathology report is required when claim is submitted for payment. 037 Periodontal surgery is covered only following scaling and root planing when need is documented. 038 The benefit for a partial denture includes all teeth and clasps. 10

13 Dental Program Explanation of Benefits Codes and Messages Message Code Message 039 Treatment involving the following is not covered: a. Specialized techniques. b. Precision attachments. c. Personalization or characterization. d. Experimental procedures. e. Surgical correction by grafts for denture retention. f. Appliances, restorations or surgical procedures to restore tooth structure lost due to abrasion, erosion or attrition or to alter vertical dimension. g. Interocclusal recording, analysis and records. h. Unusual diagnostic techniques. i. Root canal therapy, posts and restorations associated with overdentures. j. Stressbreakers. 040 The following procedures are not covered for patients under age 16: a. Cast frame partial dentures. b. Fixed bridges. c. Cast metal, porcelain and laboratory processed restorations. d. Nightguards. e. TMJ treatment. 041 Prosthetic appliances are covered once in a five-year period. 042 Interim partial covered when replaced with permanent prosthesis no sooner than two months following placement of interim partial. 043 Benefits for crowns, inlays, onlays or labial veneers are payable only if extensive coronal destruction is documented by x-rays, oral images or study models and the tooth cannot be restored with a filling. 044 Posts are covered only when insuicient coronal structure for crown retention is documented by pre-root canal therapy x-rays. 045 Cast metal crown benefits are payable for porcelain veneer crowns posterior to first maxillary molars and second mandibular bicuspids. 046 The documentation submitted does not demonstrate the need for restoration involving the incisal angle. 047 The benefit for a post and core procedure includes the core material. 048 Benefits are not payable for both a posterior bridge and a removable partial denture placed in the same arch within a five-year period. 049 Distal extension posterior cantilever pontics are not covered. 050 Where a space is largely closed and neither abutment tooth requires a crown, a fixed bridge is not covered. 051 Replacement of a second molar is not covered unless as part of a prosthesis replacing adjacent missing teeth. 052 No benefit payable per plan section 10.03(a) as: a. The x-ray appears to demonstrate periapical pathosis. b. The x-ray demonstrates tooth is present. c. The x-ray demonstrates tooth is missing. d. The X-ray/photo does not show recurrent decay or defective existing restoration margin. e. The x-ray appears to demonstrate decay at/or below the level of the bone. f. The x-ray appears to demonstrate decay into the nerve. g. The x-ray appears to demonstrate advanced periodontal bone loss. h. The x-ray appears to demonstrate decay into the furcation. i. The x-ray demonstrates root surface calculus. j. The x-ray demonstrates interproximal decay. 11

14 Explanation of Benefits Codes and Messages Message Code Message 053 A fixed bridge is not covered where there is a large number of missing teeth in the same arch and/or moderate to advanced bone loss is evident. 054 Benefits for replacement cast restorations include recementation of the previous cast restoration within 12 months. 055 Cast restorations or bridges are covered once in a five-year period, except as specifically allowed for by the Plan. 056 When a filling is replaced with a cast restoration within one year, the benefits paid for the filling will be deducted from the benefit payable for the cast restoration. 057 Benefits paid for surgical procedures include postoperative care and postoperative x-rays. 058 General anesthesia is covered only when administered by an oral surgeon or anesthesiologist for full and partial bony extractions and other complex procedures. 059 Premedication is covered for patients under the age of five and for documented handicapped or uncontrollable patients. 060 Repair, restoration or recementation within 12 months of initial placement or prior recementation or repair is not covered. 061 The benefit payable for this service has been applied to a previous overpayment. 062 Benefits are not payable because the documentation submitted does not demonstrate dental necessity. 063 The correct code for the procedure described and performed is: a which is not covered under the Plan. b which is not covered under the Plan. c which is not covered under the Plan. d which is not covered under the Plan. e which is not covered under the Plan. f which is not covered under the Plan. 064 No benefits are payable as our records indicate the tooth is missing. 066 Benefits for the replacement of this tooth are included in the benefit allowed for a partial denture. 067 A filling benefit has been paid in lieu of benefits for a crown, inlay or veneer. 068 Claims must be submitted within one year of the date services are completed. 071 Benefits are not payable for palliative or emergency treatment performed the same day as any other procedure. 072 Emergency exams and/or dispensing prescriptions are not considered palliative treatment. 074 Oice visits are not covered. 076 Temporary appliances, fillings, crowns and recementations are not covered. 077 Pulpotomy or pupal therapy on a permanent tooth is not covered. 078 There is no Plan allowance for this service. It is not a Covered Procedure under the Plan. 079 A prophylaxis benefit is payable in lieu of the benefit for the service submitted. 080 X-rays and/or periodontal pocket charting do not document the need for this procedure. 081 The documentation submitted demonstrates necessity for treatment of one to three teeth; therefore the benefit allowed is equal to: a. Procedure code 4342, root planing - one to three teeth. b. Procedure code 4261, osseous surgery - one to three teeth. c. Procedure code 4211, gingivectomy orgingivoplasty - one to three teeth. 082 Benefits for root planing are payable once per quadrant in a two-year period. 083 Periodontal reevaluation is covered four weeks after a course of scaling and root planing visits and once every 24 months thereafter. 12

15 Dental Program Explanation of Benefits Codes and Messages Message Code Message 084 Benefits are not payable for this procedure as determined by dental consultant review. 085 Benefits paid as second carrier. 086 Benefits for the extraction of this tooth will be allowed equal to: a. Procedure code 7140, extraction of erupted tooth or exposed root. b. Procedure code 7111, coronal remnant extraction. c. Procedure code 7210, surgical removal of erupted tooth. d. Procedure code 7220, soft tissue impaction. e. Procedure code 7230, partial bony impaction. f. Procedure code 7240, complete bony impaction. 087 Please refer to correspondence sent under separate cover. 088 The benefit for: a. A partial denture has been approved in lieu of the benefit for a bridge. b. An individual cast restoration has been approved in lieu of the benefit for an abutement crown. c. A buildup has been approved in lieu of the benefit for a post and core. d. A prefabricated crown has been approved in lieu of the benefit for a cast restoration. e. Procedure code 0120 has been approved in lieu of the benefit for the evaluation code billed. f. Procedure code 9310 has been approved in lieu of the benefit for the evaluation code billed. g. Procedure code 9230 has been approved in lieu of the benefit for procedure code HMO co-payments are not payable under non-duplication COB, balance is patient responsibility. 091 Benefits for restoration of accessible facial, lingual or occlusal crown margins will be paid in lieu of benefits for crown or bridge replacement. 092 Prime carrier contractural discounts are not covered per Plan Section 10.14(a). 093 Primary coverage payment exceeds this Plan s benefit. Under non-duplication COB, balance is patient responsibility. 094 Charges for this procedure were paid 100% by the primary coverage. 095 The Participant is enrolled in a Prepaid Dental Plan and is not eligible for Indemnity Dental Plan benefits. 096 Provider courtesy discounts are not covered per Plan Section 10.14(a). 098 The Fund does not have a student certificate on file for this date. Contact the Fund Eligibility Department for more information. 099 The Participant is not eligible for benefits. 100 Benefits for this service are payable once every: a. three months. b. four months. c. six months. d. 12 months. e. 24 months. f. 36 months. 102 Additional accident benefit paid for this service. 104 Restorations placed within 12 months of sealants are not covered. 105 Benefits are not payable for sealants placed on teeth that have had a previous restoration. 106 Benefits are payable for periodontal maintenance performed three months after periodontal surgery. 107 Overage dependent; no benefits are payable under the Plan. 13

16 Explanation of Benefits Codes and Messages Message Code Message 108 Services are considered medical in nature and have been referred to the Medical Department. 109 Benefits are not payable because services are considered medical in nature and the Participant is enrolled in an HMO. 110 The patient is not eligible for benefits. 111 Benefits are not payable for restoration or extraction of exfoliating teeth. 112 Benefits are approved pending receipt of x-ray documentation indicating satisfactory root canal treatment. 113 Maximum benefits were previously paid for orthodontic records and x-rays. 114 Maximum benefits have been paid or authorized for this service. 115 Benefits have been reduced by a previous allowance paid for a palliative or emergency treatment. 116 The additional accident benefit was previously paid in full. 117 Specialists consultation/evaluation benefits are payable only for the initial evaluation by a periodontist, endodontist, pedodontist, prosthodontist or oral surgeon. 118 Removal of implant fixtures and related services are not covered. 119 Maximum TMJ benefits were previously paid. 120 Treatment was not started/completed within the eligibility extension period. 121 Benefits are not payable for alveoloplasty performed in conjunction with extractions. 122 Benefits are not payable for a nightguard, TMJ appliance or TMJ oice visits in conjunction with active orthodontic treatment. 123 Additional accident benefits are payable only for injury to natural teeth and for services performed within 90 days of the accident. 124 A benefit for a recall x-ray series is payable in lieu of benefits for full mouth x-rays. 125 The allowance provided is the patient s copayment. 126 These charges were previously considered; refer to prior payment, denial or preauthorization. 127 There is no change in the previous determination as no new documentation was submitted. 128 Oral/facial photographs are not covered unless they are requested and received by the Fund or are used by the Fund in the evaluation of a case. 129 Anterior space maintainers and related charges are not covered. 130 Coverage has terminated. Preauthorization/payment is being provided under the Plan s 35 day eligibility extension period. 131 No benefits are payable as the Participant did not elect to enroll in Retiree dental coverage. 132 Benefits are not payable on an unerupted tooth. 133 No benefit payment can be made to a prior Prepaid Dental Plan for 12 months after disenrollment from that Plan. 134 This claim has been closed as the requested photos or study models have not been received. 135 A benefit is payable for a single band-type space maintainer when a bilateral space maintainer is not necessary. 136 Benefits are payable for clinical crown lengthening only when pretreatment x-rays demonstrate coronal destruction at or below the level of alveolar bone. 137 Benefits are not payable for this service since the patient has incurred no liability. 138 A copy of the primary insurance carrier s EOB must be submitted when billing. 139 Pulpal therapy or pulpotomy is covered once per primary tooth. 14

17 Dental Program Explanation of Benefits Codes and Messages Message Code Message 140 Interim partial dentures are covered for recently extracted anterior teeth only. 141 Rebill with the correct CDT procedure code for the service rendered. 142 Noncompliance with Working Spouse Rule; benefits reduced to 40%. 143 This claim has been closed as the requested information has not been received. 144 Procedure code submitted is not a valid CDT code. Rebill with valid code. 145 Annual deductible applied. 146 Annual maximum benefit has been paid. 147 Service only covered when a copy of an oral pathology report is submitted with the claim, per section 10.10(d) of the Plan. 148 When two treatment plans are submitted at the same time by the same provider, only one treatment plan can be authorized. 149 Non-duplication COB; other insurance is an HMO; no benefits payable per Plan Sections 2.12(D),6.06(E), 7.13(E) or 12.12(A). 150 An implant is not covered if there is an adjacent missing tooth or if an adjacent tooth requires a crown. 151 If a restoration on an implant or implants replaces two or more adjacent missing teeth, the benefit payable is the allowance for a removable denture. 152 This is an adjustment to a previously processed claim or preauthorization. 153 Please resubmit with a corrected copy of the primary carrier Explanation of Benefits (EOB) statement. 155 An implant is not covered when the Plan would not cover a three unit bridge to replace the missing tooth. 156 This charge has been forwarded to the orthodontic department for additional review and will be processed once the review is complete. 157 Primary carrier s benefit is equal to or greater than 100% of the Fund s allowable expense. No secondary benefits are payable. 158 Claim denied. Other insurance information not received. 159 The alternate benefit payable is the allowance for procedure Bone grafts are only covered when the condition is a result of periodontal disease. 161 Services must be provided within 90 days after the accident occurs to be eligible for additional accident benefit. 162 The x-rays demonstrate an unfilled canal(s) with evidence of pathosis. 163 The pre-treatment x-ray does not appear to support the necessity for a root canal. 166 The x-ray appears to demonstrate an incomplete filling of the canal at the apical 1/3 with visible canal space and pathosis. 167 The complete treatment records previously requested was not submitted, only partial patient clinical records were received. 168 The maximum number of 9223 allowances payable is one per visit. 15